Provider Demographics
NPI:1194006916
Name:BRYANT, DEBORAH RACHELL (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:RACHELL
Last Name:BRYANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3322
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-3322
Mailing Address - Country:US
Mailing Address - Phone:209-533-4589
Mailing Address - Fax:
Practice Address - Street 1:18880 CHERRY VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:TUOLUMNE
Practice Address - State:CA
Practice Address - Zip Code:95379-9506
Practice Address - Country:US
Practice Address - Phone:209-928-5400
Practice Address - Fax:209-928-5412
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS266231041C0700X
CA421925163WP0807X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WS0200XNursing Service ProvidersRegistered NurseSchool